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1719A (10)
_- -- _ -_ ..._r. . . � .... .WORKERS�COMFENSATION DECIARATI`ON �; , ,, � ������w p � � q � � r . � � ` � � � I he e6���aff rm tho7 � have o certifimte of<onseM�o�self � e����` ���o� �( ]� �gU'L�f��i P�RM�T �� -: insure,or o certificaie of W�rkers'Compensation Insurance, , � n V ■ � . � ...... �� or a certified copy ihereof lSec.3800,Lab C) �� " ` �x ' . � �O►]NTY,9F LOS ANGELES f�. BI��ILDI�VG d�ND SAFE?Y�� � PolicyNo. Company : �t... �. , �-r.,�,r wa�} ,. 3`.�w3`-.,; � -.. � ` ..... , •_:. . . .,. �.,�. .. .. �_' BUILDING ' CerYfied copy is hereby fumished. F R APPLICANT TO FILL IN " a�oRess �- °�-�-' �` � Ce`rt fied topy��s filed with 1he county building inspet gWIDING � ��,,,�. ^ ' ` ' � __... `� � nooREss� •`;: ,... �� � � ,�.1: .t'�F>� �ocnuTv a . tion deparlmenL .q...-:; ' ` . . - �,�� � � � . -� y ,.w* . NEAREST ' bote .�: � � ,�:�. qPPlicani ,.#�..�., I" �P,: OTV �.. • hi�e C 21A CRO55 5T � ,:-f. - NO OF BLDGS � � A..SSESSOR � CERTIFICATE OF EXEMPTION FROM WORKERS' . SIZE OF LO7 .. NOW 6fV LOT ' MAP BOOK��� PAGE � PARCEL g' ' � � COMFENSATION�WSl)RAN�E� g � � USE TON€��� MAP . '� .. � (This'section need not be compfeted if the perm t is toc one TRI�Gi M,s� +.+.���� 6�OCK '� " LOT NO .''�� � NO ��"""' �`"" b�ndred oollars{E1001 or less) �_ . . r SPEpAI � � ... .:, �. : � . � �. ,. � . ..TEL,.- . :�. ,: " CONDITIONS � ' .�. . � I cerirfy ihai in the performance of the work for wh�ch this �WNER' � � ''` " ��NO °��- ` '- " = " ` '��� �- � permj..t.is.issued,I shall not employ any person in any manner � � DISTRICi�� .GRO'JP TY?E F FIRE PRE$CE55ED BYv'�� '„ �" � ' ADDRES6�� CONST ZONE - � - s6 as to bemme subiecf Po the VJorkers'Compensation�Laws. . . � � � . . . " - ' �� .._ ,. , . . _,. . . .... _ - _,�/ ' -��' ;, , , �, �. ;..� ,�' :=n ' CITy Z�P�� STATISTICAL CLASSIfICATION �� �AP7. CONDb. '� i � .., Dafe' . , . . APPlicanY. �:- . �— ., ARCHITECTOR .. . . ...TEL � . � - NOTICE TO APPLICANT If, a4ter,makmg th s Certrf�cate of ENG�NEER NO � CLA55 NO. -���% �owELl uNRS � � Exerript�on, you sfiould 6ecome �suble�t �o the�Workers'�.. � - �. �� - � �� ��. � � ��� � � � �' Compensation prOvisions of�he�Lahor Code,yo�i musi forth- pDORE55 - � � �. �SEWER�MAP' � ' � � �� � 1—� . with comply with.such provisions or ihis perm f shall be . ,�,�...y �t�,. > .r ,TE� t "��"'��'�' � yqLIDATION . . � deemed�revoked... . . .. � � . CONTRACTOR `.3'•�.��'.` ✓f• ''.,�^' �"'��ND.�*�"� '.'t� `� .�'SK � PG� .. - � LICENSED.CONTRACTORSDECLARATION . �.��� LIC .. . � � � 1 here6y affirm that I am�censed under proyisions of Ch6pter 9 ADDRESS�" -• � .�N0. '�.'� � VALUATION �� - � � � � � r. �.. (commencng with SecLon 7000}oP Dmsion 3 of the BUs�ness and ,��.Qo:� �r - LIC . Professions Code,and my license�s n full force and efFecf CITY �' {'� "�� ..C�ASS �''r� � $ t+`fr'` k'f"� ''' '��-� ' , � � .. � ;- .,� ; . �...+, � � `"�'`-'l S� FT. NO.OF NO OF GHEIX . -. '.' . � Litense Num6er � � Lic Class � � SIZE � STORIES 1 FAMILIES� ONE .. : . � � � { � � NEW � $. ��.. . . � . . : ;�'� Contracto '' ��� ' "�": � Date��� g �.,.�: J - DESCRIP710N OF NIORK � .. ... ' -FI . )s}-� �':j . „� , :'.;k';}t#2 ADD � . � A �I�am exempt ander Sec. � . AITER � � FINAL .. . g"�'�.y,,ei�i�,r�..... DATE B&P.C.for this reason � REPAIR �❑ .,..�s u a a�.te!�.,� . � Date' USE OF'� . .. ... . oEMOI ❑ FINAL . �� � . � . � ^ :'.,,,,,� � EXISTING BLDG. � .. gy � � � � � p� G� 3:y �4 OWN�� •. � �'"... "�� � � APPLICAIVT . TEL . . tFi t � Signature ' . . PRWT} NO � . .. . � .. � :.. .i yrY. . � ER-BUILDER�DECLARA710N . . � � � ► � � �++�*r p���f+�+4„ � I hefeby affirm 4hoi I om exempt from Ihe Contrqclor's License . � qDDRE55 � � � � r�� Ldw foP the following�reason(Section 7031.5, 6usiness and . ' � . . �'���'���^�?_��� Professions CodeJ: . �BUILDING . .. � ... . .. .� . .,�� . .. . . `���� �� I,�as owner of Ihe property,�or my employees with � � ADORESS . - � � : � � � � � wages as their sole compensotion,will do the work and . �OCA�ITY � � � � �� the str�cture is not intended or offered for sale.(Seciion � , . � '.'��� . . � 7044,Business and Professions Cade) ��� � MOV,NG � �� ���TE� . � ' - - - � . �. ��I,as owne[of fhe property,am exciusively contraciing��,�� CONTRACTOR NO . . _ . � - with licensed controcrors�to wnsfruct the proje<f(Ser��. ADDRESS ��� .� � - � tion 7044,Business and Pro4essions Ccde). � �� � . �� . � � �� REQUIRED yqkp'�� HWY� ?OTAI SETBACK FROM .� E%I57:�' . . . . � CONSTRUCTION LENDING AGENCY ����� � SET&ACK ?ROP LINE WI�TH ► . - - I hereby affirm that there is a tonstruct on lend ng agency for FRONT � � � � . . � � the-peiformance of the work for which this permit is issued �. P.L .� � � . _ . � . ... . ._ ... ^:�� (Ser..�3097,Gv�:�C.). .. . . . . . SIDE' . . .. . . . . . ... . P.L..:, - . ' , Lender's Name � � - � � . � P.C.Fec$ � Parmlt Fee - .W''." :, r"��� . . . Te�`"Lender'sAddress:..�_ . . �. �� .. . . � . � - � � ; '�I ce�tify tho�I have read ihis dpplication�and sture ihat the�� � issuance Fee� ^'"�..- ���.�� +. >I , . . � �� � �- � � � � �'�����aboveinformationis,corre<1.I�agreetocomplywith�alfCounty�� in�estgpranFee " - � . , ::�, � . . � � � . - � ��ordinpnces and State laws relating to building construction, iotol.Fee � ' `•o � . � - � � � � and Fiereby authorize ra�resentatrves of Ph�is Counry to��enter �"� � ,_ . . . � . - � �� � - -� � � - � upon ihe above mgnti ne.d property for inspetl on p�rposes. ' -; . �. . , � �R..,;. . . . .., .- . ^ . �. . . ,�, - . �. .�„ _ . a . ,,.... ,�.. .. .. ��+ I �'��¢` _ � .,",r SEE REVFRSE FOR�7(PLANATOHY LANGUAGF . . - ._ . - , : . .c . . _. � . ,��� ., - � , . ,e ,_ . . ... -- . .. . .. � � ,. ..:,�.: . ;_,...Bi . . .;.Signature of Applicant ur Agent Dore .�. �. .. . . � , " ... �. . . .� � �,. ;.�,...., .. ... ,w�. ,-,.,- .�s n _r .�z=� ,� .,.� ,.w�.v .. .G _.n�,x�a�x. ,s,, r�, � , . _. ,:. -+ � �..� , ,: ...F ����..:�:+.,� �'" '„�..�s� ... ..,... ., r. . . ,... .. . . .�. �'-�.-..�A+++��': __ _ . , . . , . . < : . . _, _._ __. - _ _. _ . : .:��,.,. � �: ;.,��.. , .� � � �_ __ _�_. _ ___.�,� ��„ �� ,., ,_:-r . �.,.; � . .�,�. .�._�.:�.w G,.�:� _ ,..._. . __ ,: ,,.. _ _ _ _ _ _ t...: : � ,T- - �-�� � . . >_� . �� ...- �_ , ,r. , M _ , r �_ ..� � _ _ , A_�. t � -----.,....-------i ---�._....- -� - -•-- -- ' ' I '. ...' i I _ : I . , . . - -�� ` . � � '_' , � i ... . � l'----� � , �. . , . � I , 1 � � � � � � � - �. .. � -.._....... } _ � , ; , ; . • . i ! 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